Provider Demographics
NPI:1407228620
Name:SMITH, COLTEN J (PA-C)
Entity Type:Individual
Prefix:
First Name:COLTEN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10123 SE MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2532
Mailing Address - Country:US
Mailing Address - Phone:503-251-6155
Mailing Address - Fax:
Practice Address - Street 1:10123 SE MARKET ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2532
Practice Address - Country:US
Practice Address - Phone:503-251-6155
Practice Address - Fax:503-261-6769
Is Sole Proprietor?:No
Enumeration Date:2015-10-27
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA197416363A00000X
AZ6240363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant